United States Masters Swimming New Jersey LMSC 2012 Membership Application

Last Name

First Name

MI
 

 

Mailing Address
 

 

City

State

Zip+4
 

 

Home Phone Number

 E-Mail Address:
 Required for
 FastLane Notification

 

Work Phone Number

Date of Birth:

Month

Day

Year

Age

Sex
 
 

 

Club Affiliation(circle one):
UNAT(default)

BERK - Berkeley Aquatic Masters
BRG - Bridgewater JCC
DRMS - Ranger Aquatic Masters
GSM - Garden State Masters
HOBO - Hoboken Masters(was STVN)
JAM - Jersey Area Multisport
RBAY - Raritan Bay Area YMCA(was BCYA)

NYCS - NYC Swim Virtual Club

Workout Group Affiliation(or Swim Location): 

 

             Check if you are
   _____ a swim coach

              Check to NOT receive
   _____ USMS National Office info alerts

 

              Check if you are
   _____ a swim official; Organization =

              Check to NOT receive USMS Sponsor EMails from National Office
   _____           Note: Sponsors do NOT receive member EMail addresses

Note: if unsure of your workout group, after referring to NJ's workout group list, enter your usual practice location.
Note: Birth date and Waiver Signature are REQUIRED for registration.
WAIVER: I, the undersigned participant, intending to be legally bound, hereby certify that I am physically fit and have not been otherwise informed by a physician. I acknowledge that I am aware of all the risks inherent in Masters Swimming (training and competition), including possible permanent disability or death, and agree to assume all of those risks. AS A CONDITION OF MY PARTICIPATION IN THE MASTERS SWIMMING PROGRAM OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: UNITED STATES MASTERS SWIMMING, INC., THE LOCAL MASTERS SWIMMING COMMITTEES, THE CLUBS, HOST FACILITIES, MEET SPONSORS, MEET COMMITTEES OR ANY INDIVIDUALS OFFICIATING AT THE MEETS OR SUPERVISING SUCH ACTIVITIES. In addition, I agree to abide by and be governed by the rules of USMS and NJ-LMSC. Use of Image/Likeness: I grant permission to U.S. Masters Swimming and its affiliates to use my likeness and/or image in photographs, video, motion pictures, recordings, or any other record for legitimate purpose.

Signature:________________________________________ Date (mm/dd/ccyy):______/______/_______

Registration and benefits of membership from this application will expire on December 31, 2012.
Benefits of membership include: A subscription to USMS SWIMMER Magazine and The Fast Lane (newsletter) during the length of the membership year.
USMS Registered swimmers are covered with secondary accident insurance:
  1) In practices supervised by a USMS member or USS certified coach where all swimmers are USMS registered.
  2) In USMS sanctioned meets where all competitors are USMS registered.

2012 Registration Fee: $41.00 [USMS($31) + NJ-LMSC($10)]
(after 8/31/2012: $34.00 [USMS($26) + NJ-LMSC($8)])                  Enter amount=>

 

I wish to contribute $1.00 (or $ _______) to the USMS "Swimming Saves Lives" Fund
I have added this amount to my registration fee

 

I wish to contribute $1.00 (or $ _______) to the International Swimming Hall of Fame Foundation.
I have added this amount to my registration fee

 

I wish to contribute $1.00 (or $ _______) to NJ-LMSC.
I have added this amount to my registration fee

 

Add $18 ($9 after 8/31/2012) to registration fee
to provide hard copy mailing of the newsletter

 

Total Amount Enclosed
.

 

Submit this form, along with a check for Total Amount, including all additional fees. Make payable to NJ-LMSC.
Mail to: Tom Brunson, 11 Garret Drive, West Paterson, NJ 07424-2767